Family Physician Recruitment Request

Please complete this form to submit a request for assistance with recruiting family physicians for your clinic. Please note, all information collected in this form will be shared with Shared Health, your local health authority, and with Canadian Health Labs, the consulting firm assisting with recruitment efforts.

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* 1. Clinic Name and Information

Clinic Name

Address

City/Town

Postal Code

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* 2. Contact Name and Information

Name

Phone Number

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* 3. Please complete the following information about the current physician resources in this clinic.

Number of physicians working in clinic:

Equivalent full time (EFT) physicians working in the clinic:

Number of patients:

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* 4. Please complete the following information about the current physician vacancies in this clinic.

Number of physicians vacancies:

Equivalent full time (EFT) physician vacancies:

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* 5. Are you currently recruiting recruiting physicians?

Yes